GW1-2021-07905_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GEM-1) For Internal Use Only:
1.Well Contractor Information: "tea
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Well Contractor Name
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NC Well Contactor Certification Number
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Compan Name � ��7yy� / 16:1NNER�CAS1AiG"OR7'UB1NG.
2.Well Construction Permit#: y 1.l) �t� FROM TO I DIAMETER I TMCKNM MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Ykiriance,etc.) ft• f is
3.Well Use(check well use): ft'
Water Supply Well: FROM I TO I DIAMETER SLOT SITE TfUCKNM I MATERIAL
❑Agricultural ❑M� unicipal/PubGc fL ft. la.
❑Geothermal(Heating(Cooling Supply) fe3Rtrs'rdentiai Water Supply(single) ft• ft• In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;. a r
s_1tR_GROU.
DIrrioation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT WMOD A AMOUNT
Non-Water Supply Well: 0 ft. O ft r'Q4aa4i AOMW
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. fL
[]Aquifer Recharge ❑Groundwater Remediation
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENI MEr90D
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20DR1GLING'1sOG.attacha`dditloot';sheetiifa r;..;-fir
Geothermal(Heating/Cooling Return []Other(ex lain under#21 Remarks) FROM To DFscRipnox color tuada soluroelc eta
❑
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4.Date Well(s)Completed: t/-I id I Well ID# 3
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5a.Well Location: jo ft. J-,O R s4'1)
INL/e 0►2 C Q_ 6 PA *m 95 fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
RV) y�pk`nS �y�o� , I`_� ft. &
Physical Address,City,and Zip ft. M
1l& 2L-'REINARKS . _ r
County Parcel Identification No.(PIN) �n it
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): l3Permanent or ❑Temporary Signa of Certified Well nnaaor Date
__� By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L�JiVo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below lead surface: Al (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple weAs list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: ( ) 24a• For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above caring,use op
f Borehole diameter l0 (in.) 24b.For Injection Wells:Copy to!DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
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(L.Well construction method: 0 24c.For Water Su and Open-LoopGeothermal Return Wells:Copy to the
(i e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY/WELLS ONLY: 24d.For Water Wells VC,
over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /v Method of test 1 rmit Pe Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-201 S